Station 63
Arun Sharma
Age: 73 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of dizziness
- Clarify the nature of the dizziness, is it a sensation of light-headedness or a spinning/vertigo-type sensation?
- Ask how long each episode of dizziness lasts
- Ask about potential triggers, does it occur on standing up, during exertion, or after prolonged standing?
- Ask how often it happens and if this is getting worse (to determine severity and how this is impacting patient)
- Ask about associated symptoms, including palpitations, chest pain, or breathlessness during the episodes
- Ask if the patient has experienced any falls — if so, how many, and whether any injuries were sustained
- Ask about any history of recent head trauma, viral illness (e.g. flu), or ear symptoms (to rule out alternative causes)
- Explore the impact of symptoms on daily activities and quality of life
- Ask if patient drives and if this is affecting driving
- Inquire about hydration and dietary intake, particularly fluid consumption
- Take a psychosocial history — including who the patient lives with, smoking and alcohol history
- Provide a working diagnosis of possible orthostatic (postural) hypotension
Example of explanation to patient
Mr Sharma, thank you for sharing what’s been going on. From what you’ve described, it sounds like you might be experiencing something called postural hypotension. That’s when your blood pressure drops a bit when you stand up, which can make you feel light-headed or dizzy, especially if you’ve been sitting for a while or standing for too long.
To understand this better and make sure we’re not missing anything, I would like you to come into the surgery so we can check your blood pressure, both sitting and standing and check your pulse. We might also review some recent blood tests, or do new ones if needed, just to check things like salt levels, kidney function, and whether your blood levels are low (anaemia). Are you happy with that?
One possible reason this could be happening is your current medication. You were started on bisoprolol some time ago for palpitations, but since those have stopped and your heart tests came back normal, it’s probably no longer needed. We can stop it for now and keep an eye on things. If the palpitations come back, we can always reconsider it. Does that sound okay?
You’re also on amlodipine and ramipril for your blood pressure. Both are good medicines, but they can sometimes contribute to dizziness. Depending on your readings, we might look at adjusting the dose of one of them to help.
I know you were worried about whether this might stop you from gardening — and I want to reassure you that in most cases, it doesn’t have to. A few simple steps can really help such as standing up slowly, keeping well hydrated, not skipping meals, and taking regular breaks while doing tasks like cleaning or gardening. Would that sound manageable to you?
And just to give you peace of mind, as you live alone, we can also organise a falls alarm, just in case you ever have a fall at home, it means help can get to you quickly and it might help you feel more confident at home.
We’ll plan to see how you’re getting on in a couple of weeks. Does that all sound okay to you? Would you like me to go over anything again?
Management
Management
- Offer a face-to-face consultation to assess postural blood pressure (BP measured lying and standing) and to check pulse rate and rhythm.
- You can consider offering blood tests including FBC (to check for anaemia), U&Es (to assess electrolytes and renal function), and blood glucose. However, if recent bloods are available, these should be reviewed first and clinical judgement used to decide if repeat testing is necessary
- Offer a quick medication review: Stop bisoprolol, as it was initially prescribed for palpitations that have since resolved and were confirmed as benign by cardiology. It is likely no longer necessary. If palpitations recur, it can be restarted based on clinical need.
- Consider reducing or stopping amlodipine, or alternatively adjusting the dose of ramipril, as both may contribute to postural hypotension. Use clinical judgement based on blood pressure readings and overall tolerability.
- Advise on lifestyle measures to support independence and allow continued gardening: rise slowly from sitting or kneeling, stay well-hydrated, avoid skipping meals, take breaks when cleaning, and eat a balanced snack before physical activity
- Discuss falls prevention as the patient lives alone; suggest a falls alarm device which can be arranged through the frailty practitioner, community occupational therapist (OT) or social prescriber.
- Offer a review of blood pressure again in 2 weeks following any medication adjustments
- Provide safety netting: advise the patient to seek urgent medical help if symptoms worsen, or if they experience chest pain, palpitations, or any episode of collapse
Learning point from this station:
Orthostatic hypotension is defined as a sustained drop in systolic blood pressure of ≥20 mm Hg or a diastolic drop of ≥10 mm Hg, usually occurring within three minutes of standing. It is especially common in older adults due to age-related decline in baroreflex sensitivity, reduced vascular tone, and increased sensitivity to medications, particularly in those with hypertension.
This case reinforces the importance of assessing for postural hypotension in elderly patients presenting with dizziness, especially those on multiple antihypertensive agents. Management involves identifying and adjusting contributing medications, supporting hydration and nutrition, giving practical lifestyle advice and consideration of safety measures such as falls prevention, especially in patients who live alone
Clinicians must also consider fitness to drive. If orthostatic symptoms pose a risk to driving safety, the patient should be advised to inform the DVLA. Where there is uncertainty about fitness to drive, best practice is to advise the patient to seek guidance directly from the DVLA